How a Top Cancer Center Recovered 74% of Cash from Denials

Challenge

A large, West Coast cancer-care provider shared a problem that many other hospitals and health systems also face: keeping up with moving payer targets and an ever-increasing denials workload. In addition, because of the unique nature of its patient population and cases, the provider wanted to optimize reimbursement from complex claims that can often be difficult to adjudicate and collect. After an objective evaluation it became clear to the provider that they could benefit immensely by finding a revenue cycle partner to help them overturn denials, provide root-cause analysis and meet their cash goals.

Solution

The cancer facility began its search for an RCM partner through a request for proposal (RFP). In reviewing vendors, the center soon noticed natural alignment between their needs and the benefits that a true RCM partner like R1 could bring to their operations.

“Through the RFP process, we recognized the unique skill set R1 had to offer which included attorneys, nurses and other highly skilled individuals. Finding a vendor with a good reputation was a top priority. We did our research and found R1 was highly endorsed by professional organizations like HFMA (Healthcare Financial Management Association) and Becker’s Hospital Review, and by leading healthcare providers. R1 has been reliable, trustworthy and a fantastic partner.”

The medical center ultimately selected R1 Denials Recovery to help accelerate cash recovery and ensure accurate reimbursement, and R1 Complex Claims Referrals to streamline claims management for Veterans Affairs and Bureau of Workers’ Compensation.

“In addition to converting denials into revenue, R1 truly became an extension of our revenue cycle team, regularly reporting insights to drive process improvements that lower the reality and risk of future denials.”

Results

Since going live on R1 Denials Recovery and R1 Complex Claims in 2020, the medical center has been able to recover more than $68.5 million by reversing denials and streamlining complex claims processing. It has exceeded its cash goal 13 of the 15 months since engaging with R1, days in AR have decreased and its collection rate has increased due to the high number of overturned denials.

“R1 helped us identify a carve-out issue for high-cost drugs that required a drug invoice when billed to Medicaid Managed Care plans. After implementing a claim edit to stop claims from going to the payer without the invoice, we’ve collected $400,000. That’s preventative denials at its core.”

But the benefits don’t stop with improving reimbursement and operational efficiency. Getting root-cause insights from R1’s team of denial experts, says the client, has been instrumental in preventing future denials.